Endocrine

Question 1

Define DKA
causes
Signs & Symptoms

Answer 1

DKA = diabetic ketoacidosis
- commonly associated with DM1
- body doesnt make insulin; cant get the glucose inside the cells = starts converting energy via other ways

Triggers
- indopathic
- acute stress: infections
- poor compliance
- medications (antipsychotics)

Symptoms
- BG: 250-400
- abd. pain
- N/V
- hyperventilation: trying to compensate for the acidosis by blowing off CO2
- polyuria, dipsa and othe DM signs
- obtunded (severe)

Signs
- tachycardia
- high RR
- hypotension
- decrease skin turgor
- fruit ordor of breath
- kussmal respirations

Question 2

HHS/HHNK
what is it
signs
symptoms

Answer 2

HHS/HHNK : hyperosmalr hyperglycemic NON KETOTIC state

what
- a complication of T2DM ONLY!!
- the body is making a little bit of insulin: so it wont got into full ketosis BUT there isnt enough insulin to help shuttle the glucose into the cells
- glucose > 600 in these cases!!!

Why?
- non-complicance to medication is common
- acute illness is MC
- anti-psychotics too

Symptoms
- definately obtuned or letharigc (because glucose so high)
- polyuria, dipsia, visual changes and weight loss

Signs

• hypotension
• tacycardia with high RR
• dry mucosa
• decrease mentation

Question 3

Labs of DKA
BG, ABG, BHB, UA, Serum Osm, Anion gap

Answer 3

BG: > 250
ABG/VBG: show acidosis with low ph, low HCO3, Co2 could be low (if comp.) or normal
urine ketones: +
BHB (beta hydryxbutartic acid): + because any ketosis will pop this positive
- > 10 = def. DKA
- > 3-10 = probably DKA
- serum osmolarity: can vary
- anion gap: high

Question 4

Labs of HHS/HHNK
BG, ABG, BHB, UA, Serum Osm, Anion gap

Answer 4

BG: > 600
ABG/VBG: NO acidosis
urine ketones: could have a small amount
BHB: low, could be midly elevated but < 3
serum osmoalrity: HIGH: lots of glucose
anion gap: normal
will def be stupourous or comatosed

Question 5

DKA Treatment
Fluids
K+ + Mg+
insulin
acidosis

Answer 5

IV Fluids
- start with isotonic fluids: LR, NS
- if they are hypernatremia: give hypotonic (but this is rare)

if servely hypotensive and shock: ICU & give pressors

Potassium
- if K is low: hold insulin until K > 3.3 (because giving insulin will push K intracellularly)
if K is high: do not give any K in the fluids
if K is normal: can give KCl in IVF

Mag: if oyu are replacing K you nee to replace mag!!! (cofactors)

Insulin
- start 0.1 units/kg bolus of regular insulin with continuous infusion of 0.1/unit/kg/hr.

Acidosis management
- only give bicarb if the pH is < 7.0

Question 6

HHS Treatment
IV Fluids
Insulin
K+ and Mg+ managment

Answer 6

IV Fluids aggreesive treatemtn since these pt. are so hyperosmolar
- 1L of isotonic fluids per hour
- if hypernatremic = hypotonic fluids
- once glucose gets to 300 or less, change to D51/2NS

K+
- replace K if lower that 3.3 and hold insulin
- K normal: give KCL in IV
- K high: dont give K in the IVF

Mg+: ensure is good

Insulin
- start 0.1 units/kg bolus Regular insulin then continuous infusion of 0.1/kg/hr.

Question 7

what insulin therapy are those who came into hospital with DKA or HHS are the D/C with

Answer 7

all pt. need to transition to basal bolus therapy of insulin for some time

DKA: once glucose < 250, can eat and the acidosis is gone
HHS: glucose < 250, can eat and hyperosmlar is imrpoved

weight based dosing for insulin for the meantime becuase the pancreas is glucotoxic rn after teh event: needs time to recover

Question 8

Treatment of hypoglycemia

Answer 8

Hypoglycemica = BG < 70

from a variety of reasons

Treatment
- D5 infusion
- glucagon if no IV access/severe AMS
- Q1 BS checks until stable
- fix underlying

Question 9

Myxedema Coma

Answer 9

• longstadning hypothyroidism
• can be due to poor controll or acute event

think: sever hypothyroid
Symptoms
- AMS, lethargy, obtuned
- hypothermia, hypoventilation
- bradycardia
- nonpitting edema fo teh face, hands nose and lips

Labs
- hypoglycemia (if poor metabolism)
- check TSH (will be high) and T4 will be low
- check cortisol and AI labs in case

Imaging
- EKG: low voltage = pericardial effusion

Treatment
- IV levothyroxine and triiodthyronine and admit
- transition to oral meds when able to
- **hydrocortisone IV ** until you can rule out AI
- supportive care

Question 10

Thyroid Strom

Answer 10

severe hyperthyroidism
- rare, from longstanding untreated hyperthyroidism
- can be precipitated

Symptoms
- tachycardia
- hypotension
- arrythmias
- CV collapse
- agitated, anxious, delirious

Labs
- hyperglycemia
- hypercalcemia
- leukocytosis
- TSH low, T4/3 = high

Treatment
- Give BB to slow HR: propranolol (also helps convert T4-T3)
- give PTU faster acting than methimazole
- glucocorticoids
- +/- iodine after PTU 1 hour

Question 11

Adrenal Crisis
what is it

Answer 11

What
- lack of cortisol produced by adrenal glands
- primary (adrenal gland issue): thus no cortisol but no mineralocorticoid either (high ACTH being sent to adrenal but low cortisol)
- often times adrenal crisis in AI pt. is due to sepsis, surgeyr, severe stress
- those priamry who didnt up their steroid dose when stressed
- chronic pt. who didnt tape off their exogenous steroids

the crisis: usuall precipiated by the lack of mineralocoritoicoids (no ability to uptake sodium and get rid of K+)

Question 12

Adrenal Crisis
Symptoms and Signs

Answer 12

Symptoms
- weight loss
- N/V/D/C
- salt craving
- orthostasis
- HA and visual changes

Signs
- hypotension!!
- fever
- abd. pain
- hyperpigmentation (inc. ACTH with inc. promelano.)

may have hyperkalemia and hyponatremia (leading to AKI or anemia)

Question 13

Adrenal Crisis Treatment and Work up

Answer 13

Work up
- get labs: ACTH, CORTISOl, Aldosteron, Renin

ACTH stim test: get cortisol to be > 18-20(if it doesnt, AI)

Treatmen t
- IV Fluids: 1-3 L of isotonic (hypotensive!!)
- hydrocorotisone: IV continuous because it acts on steroid and mineralocorticoid receptors